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Using Technology to Align Treatment with End-of-Life Goals
Session ID 105, February 13, 2019
Kathy Blanton, RN, BSN, CPHQ, CPHRM
Director, Patient Health Management, Sutter Health
Ryan Van Wert, MD, CEO, Vynca
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Kathy Blanton, RN, BSN, CPHQ, CPHRM
No real or apparent conflicts of interest to report.
Ryan Van Wert, MD
CEO, Co-founder and Chairman of the Board, Vynca
Conflict of Interest
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Ryan Van Wert, MD
Salary: Yes
Royalty: No
Receipt of Intellectual Property Rights/Patent Holder: No
Consulting Fees (e.g., advisory boards): No
Fees for Non-CME Services Received Directly from a Commercial
Interest or their Agents (e.g., speakers’ bureau): No
Contracted Research: No
Ownership Interest (stocks, stock options or other ownership
interest excluding diversified mutual funds): Co-founder, CEO and
Chairman of the Board, Vynca
Other: None
Conflict of Interest
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The value of advance care planning (ACP)
Physician Order for Life-Sustaining Treatment (POLST) form
POLST/ACP state registries
California eRegistry Pilot
Sutter
The need for an ACP solution
Evaluation process
Key change management strategies
Implementation
Learnings
Metrics for success
eRegistry value prop and success
A look at Oregon
Agenda
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Explain the purpose and goals of implementing an EMR-
integrated eRegistry ACP technology platform across the health
system and state registry
Assess the value proposition of a dedicated ACP technology to
coordinate the sharing of POLST information across the medical
community
Show how the use of a dedicated ACP technology improves
patient engagement, system utilization, ACP document capture
rates and impacts unnecessary admissions and ICU utilization
Define the implementation and change management strategies
needed for success
Identify organizational readiness for participation in a POLST
eRegistry
Learning Objectives
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Advance care planning (ACP) is a lifelong process of personal
reflection to determine and document future care preferences.
To be successful, ACP must:
Help the individual accurately reflect on their values
Provide sufficient health-related information from the care team to
fit values within a specific context
Be documented in a way that is legal (usually at the state level)
Be conducted in appropriate settings
Be available in appropriate settings
What is Advance Care Planning?
The Current State of Advance Care Planning
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A rare opportunity to:
Improve quality care at an important time of life
Improve family experience
Reduce unwanted utilization
Achieve quality and value metrics
Achieve cost savings
What is the Value of ACP?
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ACP Supports Quality and Value Metrics
30%
83%
43%
Reduction in-
hospital deaths
Increase in hospice
use
Reduction in
hospital admissions
through systematic
post-acute ACP
program
Teno et al. JAGS 2007; 55:189-194; Molloy et al JAMA 2000; 283(1437-1444)
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ACP Improves the Patient Experience
Primary care: 686 patients over 75 years old, or over 50 with chronic illness
J Gen Intern Med. 2001 Jan;16(1):32-40, Detering et al., BMJ. 2010 Mar; 23(340):c1345
Hospitalized patients: 309 elderly patients randomized to ACP or usual care
34%
51%
65%
93%
ACP Document Types
ADVANCE
DIRECTIVES
LIFE SUSTAINING
TREATMENT FORM
STRUCTURED
GUIDES
Form to guide conversations
and communicate goals for
patients and providers
Self-developed or third party
Specifies actions if patient is
no longer able to speak
Living will, medical directive,
advance directive
Form to capture and honor
treatment preferences of
seriously ill
POLST, MOLST, MOST, etc
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Serious illness or frailty
Generally used when death is expected within a year
Communicates treatment wishes valid in the outpatient setting
Attempt CPR or not; if no pulse or breathing
Other medical intervention/treatment:
Full Selective Comfort Focused
Artificial nutrition wishes
Designed to ensure care concordant with patient wishes
Emergency medical services personnel
Emergency Department personnel
MD with patient makes final call
Nursing facility staff
Clinic staff
All other providers
Value of the POLST Form
STORE
ACCESS
CAPTURE
ADT/FTP
Web portal
HL7
Electronic completion
Centralized, HIPAA compliant
database
Patient matching
Call center
ED eFax
Web Portal
Technical Components of a State Registry
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Not-for-profit Integrated Healthcare
System
Numbers
Large ambulatory network: Ambulatory
Surgery, Urgent Care, Walk-in centers,
Home Health, AIM, Hospice
24 hospitals and 4,259 Licensed Acute
Beds to include 5 trauma centers
191,000+ Discharges 2017
868,000+ ED visits 2017
People Make the Network
Partner with more than 12,000 doctors
53K staff and 5K volunteers
3 Million Patients in 22+ counties across
100 California communities
Sutter Health Sacramento, CA
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POLST introduced through
legislation in 2008
Became effective January 1, 2009
Widespread use of POLST
across the state
At Sutter year-end 2017 (just prior
to go-live):
150,000+ POSLT forms on file
2,700 new forms each month
40% of patients aged 65+ with a
POLST or advanced directive
California Story
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Key Challenges Inappropriate care due to:
Paper form and reliance on human processing
Scan to wrong document type POLST lost in record
Scan to wrong chart POLST lost in another record
Delay in scanning of form in record POLST not available
Form does not contain all elements to be legally valid POLST not legal
Form contains conflicting wishes Cannot interpret POLST
Form legibility and/or scan quality poor Cannot read POLST
Multiple forms with no known signature date Most current POLST unclear
87% paper forms not available in an emergency
[1]
Not viewable by clinicians outside the Sutter network, and in
some cases inside our network
At Sutter, We Could Do Better…
[1] The Journal of Emergency Medicine, Vol. 44, No. 4, pp. 796805, 2013
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Clinical Care:
Concordance of Care: wherever the patient receives care
Improved timely access to POLST forms in an emergency
Enable just-in-time quality assurance for patients admitted to ICU
with a POLST that states comfort care only
Business Acumen:
Reduce healthcare legal risks
Non-concordant care or following orders on a non-legal form
Improve organizational reputation
Delivery of care concordant with patient wishes even when patient is
outside the organization network
Align with patient/population health strategy
Organizational Readiness
Participation in an eRegistry
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Engagement:
Increase patient and provider satisfaction
Increase community collaboration
Quality Data:
Ability to cull detailed data related to POLST use, choices made and
impact on care
Allow transparency of how often a POLST form is viewed
appropriately for targeted educational purposes
Mitigation or elimination of inherent issues with paper forms
Quality metrics
Education:
Improve organizational culture associated with quality end-of-life
conversations
Organizational Readiness
Participation in an eRegistry
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In 2014, determined we needed to use an external vendor (build vs. buy)
Internal requirement was to allow for concordance of care outside our
network
Committed to solving with an EMR integrated solution
Leverage technology to improve:
Advanced Illness Management (AIM) and palliative care programs
Integration with the state registry pilot
Outcomes:
ACP conversation/informed decision making
ACP document preparation and storage rates
Readmission rates ICU utilization
Concordance of care
Solution Focused Goal
Securely house uploaded POLST forms on a cloud platform accessible
by providers across the state
The EMR
could not
accomplish
this goal
The EMR
could not
accomplish
this goal
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Began work to procure funding for project and seek a vendor
All knew this was ‘the right thing to do’ but not sure a priority of senior leaders
Defined correlation to strategic goals and key change management strategies
Selected Vynca
Patient matching
eSignature
Quality checks
EMR flexibility
California SB 19 (2015) requires POLST eRegistry Pilot in two counties
Allowed us to finalize funding and gain approval to move forward with pilot
California also selected Vynca as their “vendor of choice” for state registry
pilot
We now know what to do….
but how to do it?
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Change Management
Six Strategies for Success
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1. Correlation to strategic goals
2013 Strategic Level 1 A3: Coordinate Care Across the Continuum
Level 2 A3: Integrated Palliative Care
Design and pilot scalable patient-centered Integrated
Palliative Care Model Experiment #1:
Model requirement impact:
Address clinical, operational and infrastructure gaps to
deliver enterprise wide PC
ACP strategies
Improve quality of care for patients/families
Driving to full concordance of care
Key Change Management Strategies
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2. Robust vendor choice requirements:
PHI protection
Safety
Ease of use
Adoption
EMR integration
Fit into clinical workflow
Quality
Cost
Performance improvement
Key Change Management Strategies
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3. Leverage state legislation SB 19 2015
Stay ahead of the coming requirements
Have a say in the rule making
Lead the healthcare community in your state
4. Stakeholder involvement
Blind spot identification and proactive solution generation
Processes such as Release of Information
Reporting methodology for ACP metrics
EMR decisions ensure future state matches current workflows
Testing and feedback
Training
Key Change Management Strategies
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5. Human Error Proofing
Decision to close the scan doc type POLST to all but HIM after a
period of both pathways being open
6. Robust training tools and communication planning
Cannot rely on the cascade method of communication
Go live February 2018
Key Change Management Strategies
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Training & Support Plans
Special Challenges
Big bang vs. pilot
Affects POLST access workflows for clinicians
Can potentially impact concordance of care for
one or more patients
Getting the word out!
Direct marketing to providers
Cascade methodology
Other tools for individual education
IT support
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Access: User Roles
Default Configuration
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What we Learned
Care risk as patient moves through
geographies
Not technically possible with one
instance of Epic
Not
possible
to pilot in
small
scale
Most ROI types include POLST form
and release is automated
Pulls scanned doc type POLST
Manual ROI not an option
Release of
Information
Process
(ROI)
interrupted
Enterprise
wide go-
live
Separate
interface
to allow
all
POLST
docs to
return
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What we Learned
POLST link found in patient level data;
some staff had encounter level access
only
Personnel
access
templates
to POLST
link
Unaware Haiku photo forms stored on
separate BLOB server not included
in upload of forms
Survey of
POLST
storage
locations
challenging
Developed
access
though
snapshot
Temporarily
re-opened
media tab
view to doc
type
POLST
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What we Learned
Entered signature dates when scanning form
would allow software to identify most current
valid form
One Touch+ (inpatient) had this functionality;
only an issue in ambulatory setting.
Hyland
OnBase did
not allow for
signature
dates
Still many paper forms used which cannot be
read for content
Care at end-of-life requires manual chart review
which is not feasible
Elusive
concordance
of care rate
eTool use
is the
solution
Plan
development
in process
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What we Learned
Change in high-value
low occurrence
workflow requires deep
communication
penetration
Risk: providers use old
POLST viewing method,
do not see a POLST,
assume patient does
not have a POLST:
Potentially results in
care not concordant
with wishes
Messaging
to
providers
at this
scale
Short messaging
Prioritize messages
Many platforms/venues
Champions
Tool kits
Utilize vendor expertise
Face-to-Face, simple fun
posters, fliers, and
“2clicks” sheets best
methodology
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2017: Before Go Live:
150,000+ POSLT forms on file
2,700 new forms each month
40% patients 65 years and over with an ACP document
Post Go Live February 2018:
More than 180,000 existing POLST were located and back-loaded
Electronic access to all of these forms within the EMR
In first 14 weeks, 764 ePOLST documents were completed
Now track who is engaging with POLST forms
Majority of forms were completed by providers who are able to
legally sign the forms
Initial results 3% of forms having nurses/social work involvement
in preparation
Metrics for Success Sutter
Metrics for Success – Sutter November ‘18
Metrics for Success – Sutter December ‘18
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Next Steps for Sutter
Final closure of historical workflow in EMR
Awareness and Utilization Campaign to drive eForm use
Benefit awareness
Data use (form access count by provider type, medical group, clinic)
Optimization
Associated EMR functionality
Yes/No form presence flag
Auto complete of MD/NP credentials
Metrics
Just-in-time patient intervention review
Continue sharing Sutter experience
Community
State
National
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Critical in building a sustainable and comprehensive approach:
1. Widespread confidence in concordance of care
2. eRegistry well integrated throughout the medical community
3. POLST data collection
Key Stakeholders:
Strong network of engaged stakeholders who support the POLST eRegistry
initiative
Address privacy and security in process of data sharing forms
Lead organization communicates clearly and frequently with community
entities
Understanding of how to participate, value, timing, and resource requirements.
Community Considerations
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Organizational readiness
Participation in an eRegistry
Self-assessment Tool
Purpose:
Explore topics which influence successful approach to an eRegistry
Explore the value prop
Identify areas which need special attention/change to be ready
Provide supportive evidence of organizational readiness to leaders
Self-assessment questions to address:
Technical, policy and operational elements
Where opportunities are identified, an internal POLST project team should convene to
discuss possible approaches
Community involvement key:
Tool should be distributed for use by other members of the healthcare community
Community members may then use the completed assessments to identify and review
areas of organization and community-wide need that may require collaborative effort
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Health Information
Technology & Data
Exchange Capacity
POLST Input
Readiness
POLST Retrieval
Readiness
POLST Project Staffing
and Administrative
Capacity
Community
Considerations
Assessment Tool
Sample of Tool
Please take
a picture of
the sample
tool at your
table
Please take
a picture of
the sample
tool at your
table
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Needs to be tied to a local group or coalition
Integration into clinical workflow
Mandatory submission of documents
Easy access to data in emergency settings
Electronic documentation
Marketing and awareness
Sustainable funding
Participation and adoption by health care organizations
What Ensures Long-term Success of a
State Registry?
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A look at the pilot in Contra Costa county
218,000+ POLST forms
Submissions portal
Available to all providers with NPI number
1,122 forms uploaded
PointClickCare integration with five SNFs
American Medical Response MEDs ePCR
43 active EMS users
California eRegistry Pilot
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Oregon POLST Registry (OPR) live since 2009
Oregonians who died that had a completed POLST form
45% 2015-2016
31% 2010-2011
When POLST forms had been completed
21 weeks from death 2015-2016
5 weeks from death 2010-2011
Alzheimers and Parkinson patients completed forms earlier
Opted for more aggressive treatment
13% requested CPR
11% requested full medical treatment
A Look at Oregon
https://www.liebertpub.com/doi/10.1089/jpm.2018.0446
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Impact Across the State
IMPACT (April 2015 July 2017)
5,711
reduction in ICU
admissions when
POLST was
accessed
37%
reduction in
hospital
admissions when
POLST was
accessed
ED visits in patients who
had POLST forms
59%
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Kathy Blanton
BlantK2@sutterhealth.org
Ryan Van Wert, MD
ryan@vyncahealth.com
Questions
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Appendix
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Standard User Workflow
Signer
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Standard User Workflow
Preparer
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Standard User Workflow
Uploader
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Standard User Workflow
View Only